By K. Kurt. New Mexico Highlands University.
The decline of the rectilinear photoscanner began in 1973 with the advent of computed axial tomography cheap doxycycline 100mg mastercard. As its name suggests (single photon emission) purchase generic doxycycline on-line, ordinary g-ray emission is the source for the information order cheap doxycycline on-line. The camera or detector rotates around the patient, and the detector will observe the tracer distribution for a variety of angles. After all these angles have been observed, it is possible to reconstruct a three dimensional view of the isotope distribution within the body. A computer is used to apply a tomo- graphic reconstruction algorithm to the multiple projections, yielding a 3-D dataset. An example with Tc–99m In the example shown (to the right), Tc-99m was added to methylene- diphosphonate, which is absorbed by the bone-forming cells (the osteo- blasts). The picture makes it possible to study diseases of the skeleton, such as bone cancer. In order to un- derstand this we refer to chapter 2 where we discussed the different ways an unstable nucleus could attain a more stable state. We mentioned that in the ordinary b-decay, a neutron was transformed into a proton and an electron, which was emitted. This is a favorable reaction since the neutron mass is lager than the proton mass. The opposite reaction where a proton is transformed into a neutron is how- ever, a more diffcult process. We can however, attain this goal via two different routes; 1) electron capture and 2) positron emission. For all natural isotopes, electron capture is the usual process – because the energy between the par- ent and daughter is less than 2m c2 (m is the electron mass). However, for a number of artifcially e e induced isotopes positron emission takes place. The fate of the emitted positron is; after Illustration of the annihilation being slowed down, it will meet an elec- tron, and then either annihilate directly, or 511 keV photon form a short-lived “positronium atom”. The fnal process is an annihilation where the mass of the two particles is trans- formed into g-ray photons. A very important point is that the photons fy off in opposite directions (see the illustration to the right). We observe the two photons by detectors 180 degrees apart (coincidence measurements). We know Courtesy of Arnt Inge Vistnes from this observation that the annihilation process has taken place somewhere along the line shown in the illustration. One coincidence observation yield a line whereas two or more observations in other directions give a point (or a small area) where the radioactivity has its origin. Information on how tissue and organs functions on both the molecular and cell level. It is also possible to study changes in the brain that follows Alzheimer disease and epilepsy. Positron and positronium In connection to positron emission – we have to mention the “atom” positronium. When the positron has lost its kinetic energy and meet an electron, it is a possibility that they will exist for a short mo- ment almost like an atom (see illustration). It can be mentioned that the frst theoretical work on positro- nium was carried out by Aadne Ore in 1949. Ore was con- nected to the group of biophysics at the University of Oslo – in fact he was the one that started this group. Positronium can be either orto-positronium (parallel spins) or para-positronium (opposite spin). Aadne Ore Para-positronium decays in two photons, both with energy (1916 – 1980) 511 keV whereas orto-positronium decays in three photons (combined energy is 1. Modell av Positronium Ore published the work in two articles; “Annihilation of Positrons in Gases” and “Ortho-Parapositronium conversion”. Coinsidences for two opposite detectors are measured and a picture is recon- structed. The isotopes must be hooked on special chemicals that can transport the positron emitter to places of interest. C – 11 connected to acetate has been proposed as a tracer for prostate tumor cells. The use of F-18 F-18 can be made in a cylotron by irradiating O-18 enriched water with protons. The reaction can be written: 18 18 O +=p F +n 8 9 After the production of F-18 we have to work fast since the halfife is only a couple of hours. We know that the active cancer cells need more sugar than other cells in the body. There- fore, we hook on F-18 to glucose – and the sugar molecule will transport F-18 to the active cells – the cancer cells. Photons with energy 511 keV are measured in coinsidence by detectors 180 degrees from each other. Two different tumors were localized; a sarcoma in the right scapula (shoulder blade) and a lymphoma in the right axillary lymph. The cancers were treated by radiation and the result is seen on the series of pictures – the sarcoma to the left and the lymphoma to the right. You see that the large sarcoma in the right scapula is radioresistant – independent of the radiation dose given. The lymphoma in the right axillary lymph is however radiosensitive and is eliminated after a dose of 40 Gy. The images were taken before the start of radiotherapy (0 Gy), after 8 Gy (early treatment) and after 40 Gy (late treatment). For these methods no ionizing radiation is involved and no absorbed or scattered photons are making the pic- tures. However, Raymond Damadian in spite of this it was a sensation (born 1936) and a start of a technique that to- (photo from 2009) day is very important within med- ical diagnostics. The Nobel prize in physics for 1952 was awarded to Bloch and Purcell for nuclear magnetic resonance. Yevgeny Zavoisky Felix Bloch Edward Mills Purcell (1907 – 1976) (1905 – 1983) (1912 – 1997) 204 The physics of magnetic resonance In this book we are interested in the physical background for the different medical techniques rather than to the techniques themselves. Knowledge about x-rays and radioactive nuclides was important for the methods discussed so far. In the case of the electron it can be written as: Here b is the Bohr-magneton, S is the electron spin and “g“ is the spectroscopic splitting factor – which for free electrons is 2,0023. If these small magnets are placed in a magnetic feld B, they will attain an energy which depends on the spin state. B S S where mS is the spin quantum number for the electron, which can have two values; +1/2 and –1/2. The reonance phenomenon +1/2gbB Energy difference: hn = gbB –1/2gbB Increasing magnetic feld 205 The fgure show that all the small magnets have equal energy as long as the external magnetic feld is zero.
It is emphasized that patient dose monitoring is essential whenever fluoroscopy is used order genuine doxycycline line. Recommendations for manufacturers to develop systems to indicate patient dose indices with the possibility to produce patient dose reports that can be transferred to the hospital network are provided order doxycycline 200 mg fast delivery, as are shielding screens that can be effectively used for protection of staff using fluoroscopy machines in operating theatres without hindering the clinical task purchase cheapest doxycycline. Training for health care professionals in radiation protection should be related to their specific jobs and roles. The physicians and other health professionals involved in procedures that irradiate patients should always be trained in the principles of radiation protection, including the basic principles of physics and biology. The final responsibility for radiation exposure lies with the physician providing the justification for the exposure being carried out, who should, therefore, be aware of the risks and benefits of the procedures involved. Education and training appropriate to the role of each category of physician should be given at medical schools during residency and in focused specific courses. There should be an evaluation of the training and appropriate recognition that the individual has successfully completed the training. In addition, there should be corresponding radiation protection training requirements for other clinical personnel that participate in the conduct of procedures utilizing ionizing radiation, or in the care of patients undergoing diagnosis or treatment with ionizing radiation. Scientific and professional societies should contribute to the development of the syllabuses, and to the promotion and support of the education and training. Scientific congresses should include refresher courses on radiation protection, attendance at which could be a requirement for continuing professional development for professionals using ionizing radiation. Professionals involved more directly in the use of ionizing radiation should receive education and training in radiation protection at the start of their career, and the education process should continue throughout their professional life as the collective knowledge of the subject develops. It should include specific training on related radiation protection aspects as new equipment or techniques are introduced into a centre. A major test Adequate education and training of medical staff and practitioners is considered paramount and the major route to ensuring appropriate radiological protection in medicine. In pursuit of medical, dental, radiography and other health care degrees, education and training should be part of the curriculum and for specialists, such as radiologists, nuclear medicine specialists and medical physicists, as part of the curriculum of postgraduate degrees. The term ‘education’ usually refers to imparting knowledge and understanding on the topics of radiation health effects, radiation quantities and units, principles of radiological protection, radiological protection legislation, and the factors in practice that affect patient and staff doses. The term ‘training’ refers to providing instruction with regard to radiological protection for the justified application of the specific ionizing radiation modalities (e. Education and training are officially recognized with accreditation and certification. Accreditation and certification Organizations should be established to provide ‘accreditation’ that officially recognizes education and training on the radiological protection aspects of the use of diagnostic or interventional radiation procedures in medicine. Such organizations have to be approved by an authorizing or regulatory body, and required to meet standards that have been set by that body. A system of ‘certification’ shall be established for officially stating that an individual medical or clinical professional has successfully completed the education or training provided by an accredited organization for the diagnostic or interventional procedures to be practised by the individual, demonstrating competence in the subject matter in a manner required by the accrediting body. As the number of diagnostic and interventional medical procedures using ionizing radiations is rising steadily, and procedures resulting in higher patient and staff doses are being performed more frequently, the need for education and training of medical staff (including medical students) and other health care professionals in the principles of radiation protection will be a more compelling challenge for the future. Fostering information exchange Fostering information exchange is another key general challenge for improving radiological protection in medicine. Intergovernmental organizations, national regulatory bodies, medical professional associations, and medics and patients themselves should be part of a rich network of information exchange. This brochure underlines, on the one hand, the obvious benefits to health from medical uses of radiation, in X ray diagnostics, interventional radiology, nuclear medicine and radiotherapy, and, on the other hand, the well established risks from high doses of radiation (radiotherapy, interventional radiology), particularly if improperly applied, and the possible deleterious effects from small radiation doses (such as those used in diagnostics). This brochure describes the dilemma of protection of patients in uncomplicated prose: appropriate use of large doses in radiotherapy prevents serious harm, but even low doses carry a risk that cannot be eliminated entirely. Diagnostic use of radiation, therefore, requires methodology that would secure high diagnostic gains while minimizing the possible harm. The text provides ample information on opportunities to minimize doses and, therefore, the risk from diagnostic uses of radiation, indicating that this objective may be reached by avoiding unnecessary (unjustified) examinations, and by optimizing the procedures applied both from the standpoint of diagnostic quality and in terms of reduction of excessive doses to patients. Optimization of patient protection in radiotherapy must depend on maintaining sufficiently high doses to irradiated tumours, securing a high cure rate, while protecting the healthy tissues to the largest extent possible. Problems related to special protection of the embryo and foetus in the 3 http://rpop. Strategy As described in the previous, vidi, chapter, the number of challenges still presented by radiological protection in medicine is enormous. In order to address these challenges and succeed in addressing them, a strategy is required. Altmaier, Federal Minister of Germany for the Environment, Nature Conservation and Nuclear Safety at the Bonn conference . It did not only consider the protection of patients and their comforters but also the related and, many times, interrelated occupational protection of the medical staff attending the patients and the protection of members of the public who are usually casually exposed from medical sources. Notwithstanding this, the Bonn conference could well follow the pattern marked by the Malaga conference. Heinen-Esser, again comes to the rescue with a relevant suggestion by declaring: “I would be delighted if we were to adopt a new action programme by the end of this week and meet the shared objective of this conference: Setting the Scene for the Next Decade. It seems that the general strategy should be the achievement of a renewed international Action Plan, this time covering all aspects of radiological protection in medicine. New standards It is to be noted that there is an important framework for such a strategy and for a new action plan. The new requirements comprehend ten specific mandatory ‘commandments’, namely: (1) The government shall ensure that relevant parties are authorized to assume their roles and responsibilities and that diagnostic reference levels, dose constraints, and criteria and guidelines for the release of patients are established. The world now seems to be ready for a serious systematic and orderly intergovernmental process for internationalizing the protection of patients and medical staff. The new Action Plan should be undertaken in co-sponsorship and cooperation with: — Specialized agencies of the United Nations family; — Relevant regional organizations; — National regulators; — Medical professional organizations; — Senior specialists in the practices of radiodiagnosis and radiotherapy, and in radiological protection; — The pertinent industry of manufacturers of medical equipment. The strategic aim of such an Action Plan should be an intergovernmental international radiation safety regime for the practice of medicine. First volume translated into Castilian: Historia de la radiación, la radioactividad y la radioprotección — La Caja de Pandora; con prólogo de Abel J. González, Sociedad Argentina de Radioprotección, Buenos Aires (2012), http://radioproteccionsar. Lahfi The role and relevance of efficacy to the principle of justification in the field of radiation protection of the patient B. Moores A preliminary study on the impact of a redesigned paper based radiology requisition form with radiation dose scale on referring clinicians — As a model for developing countries A. Ascención Ybarra Lessons learnt from errors and accidents to improve patient safety in radiotherapy centers K. Asnaashari Lahroodi Gel dosimetry for radiotherapy patient dose measurements and verification of complex absorbed dose distributions M. Castellanos Film dosimetry for validation of the performance of commercially available 3D detector arrays for patient treatment plan verifications K. Chełmiński Radioprotective effect of bolus on testicular dose during radiation therapy for testicular seminoma J. Cordero Ramírez Issues on patient safety during radiation therapy — Concerns of regulatory authority P. Dubner Organ and effective doses from verification techniques in image-guided radiotherapy V. Dufek Application of the risk matrix approach in radiotherapy: An Ibero-American experience C.
Laboratory studies show normal hepatic enzyme activities discount doxycycline 100mg without prescription, a negative direct antiglobulin (Coombs) test buy 200 mg doxycycline with visa, increased mean corpuscular hemoglobin concentration purchase doxycycline 200 mg free shipping, and increased osmotic fragility of erythrocytes. Which of the following types of erythrocyte is most likely to be seen on a peripheral blood smear? A 34-year-old woman is brought to the emergency department by her husband because of confusion for 2 hours. Her husband says that she has a 1-year history of episodes of nervousness, light-headedness, and dizziness that resolve after she eats a meal. Physical examination shows a round face, central obesity, excess fat over the posterior neck and back, and abdominal striae. A chest x-ray shows a 3-cm mass in the left upper lobe with enlargement of hilar nodes. Further serum studies are most likely to show an increased concentration of which of the following proteins? A 45-year-old man with chronic pancreatitis has a 9-kg (20-lb) weight loss and diarrhea. A 70-year-old man comes to the physician because of a 2-year history of shortness of breath and progressive chest pain. Physical examination shows absent breath sounds and dullness to percussion over the right lung base. A chest x-ray shows thickened pleura on the right side and a medium-sized pleural effusion. Microscopic examination of the kidneys shows intact nephrons interspersed between the cysts. The most likely cause of these changes in the kidneys involves which of the following modes of inheritance? An autopsy of a 24-year-old woman shows pleuritis, membranous thickening of glomerular capillary walls, concentric rings of collagen around splenic arterioles, and excrescences on the underside of the mitral valve. The external iliac arteries contain irregular, focal cystic areas within the media with pools of mucopolysaccharide and fraying fragmentation of the elastica. A 10-year-old boy is brought to the emergency department 15 minutes after he sustained abdominal injuries in a motor vehicle collision. The patient undergoes operative removal of a portion of the lower left lobe of the lung, the left lobe of the liver, half of the left kidney, half of the spleen, and a 2-foot section of the small intestine. Assuming survival of the acute trauma, which of the following organs is likely to have the most complete regeneration in this patient? A previously healthy 2-year-old boy is brought to the emergency department because of bloody stools for 2 days. Laboratory studies show: Hemoglobin 11 g/dL Hematocrit 37% Leukocyte count 9500/mm3 Platelet count 250,000/mm3 Test of the stool for occult blood is positive. During an emergency laparotomy, a 3 × 2-cm protrusion is found on the antimesenteric border of the small intestine approximately 50 cm proximal to the ileocecal valve. A 50-year-old man comes to the physician because of progressive fatigue and darkening of his skin during the past 2 years. A 69-year-old woman is brought to the emergency department because of progressive difficulty with her vision during the past day. She says, “This morning I had a blind spot in my left eye, and it just grew bigger as the day went on. Ophthalmologic examination shows visual acuity of 20/100 in the left eye and 20/40 in the right eye. A 30-year-old woman comes to the physician because of a 2-month history of unsteady gait and numbness of both legs. Eight years ago, she underwent resection of the terminal ileum because of severe Crohn disease. Sensation to pinprick, vibration, and fine touch is decreased in the upper and lower extremities. A deficiency of which of the following is the most likely underlying cause of these findings? A 10-month-old girl is brought to the physician by her father because she does not seem to be gaining weight despite an increased appetite. She has no history of major medical illness, but during the past winter she had several infections of the ear and respiratory tract that were treated with antibiotics. The chairman of a large pathology department is planning for the personnel that he will need in the future. He is trying to decide whether his department will have more need for a dermatopathologist or a cytopathologist. He decides against the cytopathologist because he expects the number of Pap smears to fall off dramatically in the future. The development of which of the following is the most likely reason for this expected decrease in the number of Pap smears? A 22-year-old woman comes to the physician because of a 1-day history of fever and right flank pain. A previously healthy 30-year-old woman comes to the physician for a follow-up visit after a chest x-ray shows bilateral hilar adenopathy and a calcified 1-cm nodule in the periphery of the right lower lobe. Specially stained sections of a bronchial biopsy specimen show no acid-fast bacilli or fungi. A 3-year-old girl is brought to the emergency department 30 minutes after she tripped and fell. Physical examination shows blue sclera and edema and tenderness over the right proximal lower extremity. X-rays show a fracture of the right femur, as well as several fractures of varying ages of the left clavicle, right humerus, and right fibula. A 50-year-old man with type 2 diabetes mellitus has a 1-week history of swelling and a feeling “like electric shocks” in his right wrist and hand. He is a computer programmer, and the shock-like feeling is worse with activity and at the end of the day. With the hand hyperextended, pain radiates into the fingers when the examiner taps the flexor surface of the distal wrist. A 3-year-old boy is brought to the physician because of a 2-day history of fever and an itchy rash. Physical examination shows multiple red papules and vesicles over the face, trunk, and upper and lower extremities. E - 54 - Pharmacology Systems General Principles of Foundational Science 25%–30% Pharmacodynamic and pharmacokinetic processes Bacteria Antibacterial agents Viruses Antiviral agents Fungi Antifungal agents Parasites Antiparasitic agents Immune System 1%–5% Blood & Lymphoreticular System 1%–5% Behavioral Health 5%–10% Nervous System & Special Senses 5%–10% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 1%–5% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 5%–10% Renal & Urinary System 5%–10% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive & Breast 1%–5% Male Reproductive 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% - 55 - 1. Ten months after starting procainamide therapy for cardiac arrhythmias, a 56-year-old man develops arthritis and other symptoms consistent with drug-induced systemic lupus erythematosus. This finding is consistent with which of the following genetic polymorphisms in drug metabolism? He has been taking a drug for the past 7 years to control severe behavioral and psychiatric symptoms associated with dementia, Alzheimer type. Therapy is started with trimethoprim- sulfamethoxazole, and his pneumonia resolves.
Redesigned Hospital Experience Improving diagnostics and treatments is not enough any more buy doxycycline now, but we need to massively improve the healthcare experience whether the process takes place in a hospital or at home cheap doxycycline 200 mg without a prescription. The delivery of healthcare must acquire features regarding the customer experience from other industries buy doxycycline no prescription. Transparent decision trees should also be available for patients after getting a diagnosis therefore informed decisions can be made with their doctors who would serve as partners in the care. And companies such as the recently launched Calico from Google will make attempts at reaching these goals. Remote Touch While the human touch is the key in the practice of medicine, after some time we will have to use remote touch due to the shortage of doctors and increasing number of patients. The force feedback technique used by the video game industry has the potential to be used in medicine as well. It has been demonstrated that biopsy sampling can be simulated in a 3D environment using a force- feedback controlled device. Surgeons could be trained with the technique to get better at a procedure even before operating on real patients. Robotic Interventions The number of studies examining the use of robots in the operating room has been increasing rapidly in the past couple of years. Robots can be used in remote surgery, surgical rehearsal in pre-operative planning, intra-operative navigation, simulation and training, among others. It is clear robotic interventions can add a lot to the success of operations and different procedures. One of the best examples is still the Da Vinci system, but other robots in the fields of emergency response or radiosurgery are also available. Surgical instruments will be so precise in a few years’ time that it will be impossible to control them manually, therefore robotic or mechatronic tools will be needed in order to reach the required accuracy. Robotic Nurse Assistant With the growing number of elderly patients, introducing robot assistants to care homes and hospitals is inevitable. It could be a fair solution for moving patients and performing basic medical procedures such as drawing blood. In the next step, it might also perform analysis on the blood from detecting biomarkers to obtaining genetic data. Semantic Health Records The only way to constantly improve a system is to generate and analyze data to find solutions for improving it. The basic requirement of improving healthcare is everyone accessing their own medical/health data stored in semantic databases facilitating public health research as well. Semantic datasets could generate alerts about upcoming medical issues and potential complications. Smartwatch Smartphones have not been able to replace pagers due to practical reasons, but an easily accessible wearable device might have the potential to make this step. A smartwatch could be used for consultations, making calls, sending messages, scheduling visits, as a pager or even for displaying fresh lab test results. We are not far from destroying all obstacles in exchanging medical information, drug, medical equipment or life itself through the so called biological teleportation and the advances of 3D printing. Virtual trials In the era of open access and crowdsourced scientific information, we will have to find a solution for conducting clinical trials without experimenting on people gathering the same amount of information in the same quality as before but in a much faster, non-invasive, humane and reliable way. Every country needs an E-patient Dave, a Jack Andraka and a Regina Holliday to fulfill these goals. Virtual Dissection Medical students will study anatomy on virtual dissection tables and not on human cadavers. What we studied in small textbooks will be transformed into virtual 3D solutions and models using augmented reality. We can observe, change and create anatomical models as fast as we want, as well as analyze structures in every detail. Patients could go through an upcoming operation step by step or choose a hospital based on its „virtual experience” package. Moreover, as the first bi-directional brain- machine interface became available, monkeys in an experiment could use a brain implant not only to control a virtual hand, but also to get feedback that tricks their brains into "feeling" the texture of virtual objects. Virtual-Digital Brains Ian Pearson, in his book, You Tomorrow, wrote about the possibility that one day we would be able to create digital selves based on neurological information. As Google hired Ray Kurzweil to create the ultimate artificial intelligence controlled brain, this opportunity should not be so far away. We might have been searching for the clues of living forever in the wrong places so far. Wearable e-skins Measuring easily quantifiable data is the key to a better health, therefore the future belongs to digestible, embedded and wearable sensors; the latter working like a thin e-skin. These sensors will measure all important health parameters and vital signs from temperature, and blood biomarkers to neurological symptoms 24 hours a day transmitting data to the cloud and sending alerts to medical systems when a stroke is happening real time. Examples include hydration sensors for athletes and intelligent textiles that change color indicating diseases. Whether you are a patient or a medical professional, follow the 1 main trends and try to be up-to-date by using digital methods. Constantly look for solutions to improve your practice as a 2 medical professional or your health as a patient. Embrace digital in a comfortable way and use techniques that 3 make your life easier and your work more efficient. No matter how important role digital will play in our lives, human 8 touch is and will always be the key in the doctor-patient relationship. You Tomorrow This work is licensed under the Creative Commons Attribution-NonCommercial- NoDerivs 3. The formation of the Ghana Psychic and Traditional Healers Association in 1961 and the establishment of the Centre for Scientific Research into Plant Medicine in 1975 attest to this fact. Also in 1991 the government established a unit for the coordination of Traditional Medicine (which is now Traditional and Alternative Medicine Directorate) which was followed by the setting up of the Food and Drugs Board in 1992, which among others, is to certify the sale of Traditional Medicine products to the public. Although all these documents provide a legal policy framework for the development of Traditional Medicine, there is no single document that coordinates the general policy direction of government in the area of traditional medicine. It cuts across sectoral boundaries and provides a national position for which all sectors have to buy into. Almost all the relevant traditional medicine institutions and organizations were involved in the process of developing the document. Others included were Sociology and Biochemistry Departments of the University of Ghana and the Faculty of Pharmacy of the Kwame Nkrumah University of Science and Technology. It is hoped that the document will be relevant to all government institutions working towards the development of Traditional Medicine. The potential of traditional medicine has been recognized by successive governments. The establishment of the Traditional and Alternative Medicine Directorate of the Ministry of Health is to coordinate the activities of policy initiation and implementation. For the Directorate to work effectively there is the need for a general policy direction for coordinating activities in the area of traditional medicine. The objective is to provide a general policy direction or framework within which government short to long term plans on Traditional Medicine would be based.
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